PACES MRCP UK - Where MRCPians Meet Since 2006

MRCP is well establised as an entry exam for advanced specialist training in many countries including Malaysia. It consists of 3 paper i.e. Part1, Part2(written tests) and PACES. PACES in full means Practical Assessment of Clinical Examination Skills. It is the third part and the candidate is assessed by fellows of RCP. I passed my PACES in 2005. I am glad that many seniors had guided me throughout my preparation for PACES and I wish to share my experiences with PACES candidates via this blog.

Monday, April 30, 2007

Station 5 - Acromegaly, Uneasy To Get "4" For An Easy Diagnosis

During my singapore PACES exam, i got an acromegaly case. The stem being " please examine the patient's hands".

By one look at the patient, we are happy to conclude that the patient has acromegaly, the next thing in my mind is what the examiner want me to pick up from the patient's hands with acromegaly.

Possible things to pick up:
1) Carpal Tunnel syndrome
2) Osteoarthritis
3) Pure hand feature of acromegaly

We may easily get a 4 mark if we follow the stem, go accordingly to point out the features that support the diagnosis.
Steps to follow in order for acromegaly patient in the very moment of 2 min before we use up 3 min for presentation.
1) Hand : large spade like hand, doughy hand, sweaty palm, tinel's sign

2) armpit: especially to look for skin tag (most candidate miss it, and we may only get 3 if we miss it)

3) Face: Prominent supraorbital ridge, prognatism, widely-space teeth, macroglossia, increase in skin creases/ wrinkles

4) Visual field assessment -bitemporal hemianopia

5) Lower limb: large foot, osteoarthritis of knee, thicken heel pad

6) complete by mentioning: checking BP, urine for glycosuria, examine for galactoria

Present as such order to make it systematic but the opening sentence must be base on the stem, in this case, "examine the hand"
This patient has features of acromegaly. I say so because she has a large doughy, spade like hand. Her palm appeared sweaty. There is evidence of carpal tunnel syndrome as the tinel sign is positive. I found a skin tag over her right axillary area. Her voice appears to be coarse, she has prominent supraorbital ridge, and prognatism. She has macroglossia with widely-space teeth. Her foot appears to be large. Her heel pad is thickened. There is sign of osteoarthritis over her knee joint. There is no evidence of bitemporal hemianopia.

In conclusion, Mdm X has acromegaly. The most likely cause is a macroadenoma. There is sign of active disease in view of presence of sweaty palm, and skin tag. I would like to further assess her cardiovascular system.

These are the questions the examiner asked from me: ( not much time left after my presentation)
1) How do you confirm the diagnosis
Answer: Failure of suppression of GH level to less than 2ng/ml after oral glucose confirm the diagnosis
2) What further test you want to do?
Answer: Localization of pituitary tumour by requesting a MRI of brain
3) What are the treatment?
optimization of cardiovascular risk by strict BP and sugar control, refer eye for Visual field perimetry, definitive treatment: transphenoidal hypophysectomy, medical: somatostatin analogue: Octreotide, GH receptor antagonist: Pegvisomant

That end the session with clear pass from both examiner.
Further possible question:
1) What other source of GH if MRI shows no macroadenoma?
Answer: ectopic growth hormone production, small cell CA lung
2) How do you monitor treatment response?
Answer: insulin like growth factor
3) Do you know of any endocrine adenoma association with acomegaly?
Answer: MEN type 1 -parathyroid hyperplasia, pituitary adenoma, pancreatic tumor
Need to examine calcium level

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At 4/30/2007 12:28:00 PM, Blogger Axonopathic said...

Excellent flow of thoughts during stressful period like this!

In MRCP, this is exactly what being looked for in candidates -analytical and critical sequence of thinking in seeing patients:)

At 4/30/2007 10:20:00 PM, Blogger panhypopit said...

Nothing is better than past experience. Wonderful post.

I would actually inspect for thyroid enlargement and also like to complete my Ex by examining the heart and abd for organomegaly...etc

If they ask for further further Ix, I would suggest ant pit hormone study ( don't forget my name)

At 5/01/2007 03:44:00 AM, Blogger Hospital Slave said...

While you are searching for skin tags in the axillae, don't forget to look for acanthosis nigricans.

This is a short case station. You are not expected to examine the heart nor abdomen in acromegaly. Worth mentioning during the presentation, but don't bother doing it.
The trick is: you score more points from talking (presentation) than doing thinbgs (examination).

At 5/01/2007 09:46:00 PM, Blogger panhypopit said...

Hospital slave,

I definitely agree with what you said. That is why we need to sing a song at the end of examination:
I would like to complete my Ex by examining the heart and abd for organomegaly, BP and dipstick the urine for glycosuria.

At 7/07/2007 12:26:00 AM, Anonymous Anonymous said...

if asked how can you tell if a patient with acromegaly disease is active or not, what is the full answer?

At 10/24/2007 05:11:00 PM, Blogger alok said...

sweating, hypertension, glycosuria and headaches will indicate disease activity

At 4/05/2008 11:06:00 PM, Anonymous Anonymous said...

If you really want to look slick, mention the needle pricks visible on the edge of the finger pads from blood glucose monitoring


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